As Demand for At-Home Care Grows, States Debate How to Pay for It

Most states can't meet baby boomers' demand for staying out of nursing homes.

elderly woman gets a check-up in her home
Today about 15 percent of Americans are 65 or older, a percentage that will grow steadily in the coming decades as more and more baby boomers reach retirement age. Even some boomers’ oldest children aren’t that far away from hitting that milestone. Those demographic realities will put intensifying pressure on our systems of long-term health care. How they will evolve to handle the growing demand can’t be predicted, but one aspect is already becoming clear: The boomers aren’t going quietly into nursing homes.

They want care on their terms, and a big part of that means being able to stay in their homes and communities as they age. “The trend is shifting at every level to care at home and in community-based settings,” says Kevin Prindiville, executive director of the advocacy group Justice in Aging. “People are increasingly asking for and expecting this.”

As those expectations shift, figuring out how to pay for more home-based care is mostly left up to the states. Medicaid is the primary payer for home- and community-based care, although states can decide whether or not they’ll offer the coverage. All 50 states and the District of Columbia do have home- and community-based programs of some type, but most states have waiting lists for their programs. Meanwhile, 59 percent of Medicaid funding goes to nursing homes, where about half of those in long-term care receive their services. “Nursing home institutions are a powerful player in the health-care setting, so there’s long been political pressure to not pay for more home health care,” says Prindiville.

Bucking that pressure has left California scrambling to find the money. The state is in a dispute with its county governments on how to pay for its county-administered In-Home Supportive Services, the country’s largest home health-care program. Gov. Jerry Brown has proposed shifting $600 million of the tab to counties for home- and community-based care, but county health officials say that would hurt other publicly funded health services. 

Illinois, mired for years in budget disputes, is also in a face-off on home care. The budget passed by the Democratic-led state House earlier this year would expand the state’s offerings, but Republican Gov. Bruce Rauner disapproves of the spending plan.

At the other end of the spectrum is Washington state, where fully 85 percent of residents with long-term care needs receive services at home or in a community-based setting. “We’ve done our best to make community-based care an entitlement,” says Bea Rector, the acting assistant secretary for the state’s Aging and Long-Term Support Administration.

States that want to expand their home care offerings have options that go beyond simply appropriating more money. Washington state, for example, received a federal waiver last year to offer unpaid caregivers training and respite services, and it has enacted legislation allowing nurses to delegate non-medical tasks to aides. “Even we don’t have enough nurses,” Rector says, “so we would never be able to serve all the people we do if we didn’t have statutes that allowed for flexibility there.”

Long-term care experts acknowledge that national data on home care is spotty at best, but Rector thinks progress should be measured not only by the length of wait lists or numbers of home aides, but also by that hard-to-define “happiness factor.” Policymakers should be thinking of the data “in terms of quality of life,” she says. “What difference does this service make for our residents?” 

Mattie covers all things health for Governing.

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